Szasz, Laing and Existential Psychotherapy

By Daniel Burston

In "The Secular Cure of Souls" (JSEA, issue 14.2), and a talk delivered to the International Federation for Psychoanalytic Education on November 2, 2002, entitled "The Cure of Souls in The Therapeutic State", Thomas Szasz goes to great lengths to differentiate between himself from R.D. Laing, whose life and work I have studied in some detail. It is quite true, as Szasz points out, that Szasz, Laing and Foucault are often lumped together indiscriminately as "anti-psychiatrists" by spokesmen for the psychiatric establishment, and indeed, by its critics as well. And like Szasz, I confess, I am thoroughly sick and tired of that simple-minded refrain. Admittedly, despite the sound and fury of their previous exchanges, the published work of Szasz and Laing discloses far more points of convergence and intellectual kinship than Dr. Szasz is presently willing or able to admit (Burston, 1996, chapter 8). But at the end of the day, Szasz and Laing are not cut from the same cloth. Szasz is a libertarian, Laing an existentialist, and despite their similarities on important points, libertarians and existentialists also diverge on a number of issues, as I hope to show in the pages that follow.

Having said that, it goes without saying that Szasz has made many valuable contributions to the mental health field, and that his sense of kinship with members of the SEA is not at all misguided, even though, by his own admission, he is not an existentialist. In his IFPE address (Szasz, 2002), for example, Szasz wrote that

Verbal intercourse, especially, the psychoanalytic dialogue, entails existential intimacy, often more intense than sexual intimacy. Medicalized psychoanalysis (psychotherapy) denies the quintessential intimacy of its own distinctive "method", illustrated by the obtuse conception that it is something the therapist gives or does to the patient, as if it were a surgical operation. In surgery, all things being equal, doctor and patient are fungible. In psychotherapy, as in marriage or friendship, each person is a unique, irreplaceable individual.

This statement warrants our enthusiastic and unqualified assent. Freud suggested that a detached "expert" who excises or replaces morbid tissue from the unconscious corpus of his patient represents the model for the listening and interpretive skills of someone charged with "making the unconscious conscious". But the surgical analogy for psychoanalysis is perverse, because it presupposes a patient who is passive and unconscious throughout the entire procedure, and by implication, invalidates the agency and the experience of the patient, and his capacity to affect the therapist, which are central to any meaningful therapeutic encounter . Orthodox Freudians should be ashamed for having embraced and defended such pernicious nonsense for so many years (For a thorough historical overview, see Stepansky, 1999). In calling attention to this issue, Szasz stands shoulder to shoulder with existentialists of all shades and stripes, and in various ways, has done for several decades. And I sincerely thank him for it.

Having said that, Szasz is not an existentialist when it comes to the mind/body issue. When they first appeared, of course, his remarks on "the myth of mental illness" were an invaluable stimulus to thought, because they called attention to the misconceptions that arise from the thoughtless application of the medical model to existential problems, or "problems in living", as H.S. Sullivan and he prefer to call them. Still, decades of research on psychosomatic, psychophysiological, and psychoneuroimmunological disorders indicate that Szasz's dicta are predicated on a distinction between mental and physical disease that is completely untenable . Illness, says Szasz, pertains to the body, not to the mind, as if the mind were some inviolate realm or "essence" that is separate from the body; as if mind and body were not so deeply and intricately intertwined that, in functional terms, they form a unity.

In truth, mental illness is not a myth, but an oxymoron. To say that someone suffers from a "mental" illness implies that his or her malady is mental, rather than physical in nature, when more often than not, the patient's affliction entails intense bodily suffering as well. On the other hand, to say that this ostensibly "mental" disturbance is also an "illness" implies that an organic etiology, even though one is often lacking, sometimes after more than a century of research (e.g. schizophrenia, ADD). In short, not one, but both of the tacit assumptions embedded in the term "mental illness" are tendentious, and at variance with one another. Though I am not the first to say so, of course, the phrase "mental illness" is actually thundering contradiction in terms, which perpetuates and inscribes the Cartesian mind/body dualism in the discourse of the mental health professions. If it were not so dismally commonplace, one might infer that its use is indicative of a "thought disorder".

That said the fact that Szasz is not an existentialist does not deprive him - or anyone else - of the right to criticize existential psychotherapists who have trampled on the liberties of others in the past. If existentialism has been used as a pretext to violate human dignity, we can (and should) protest. And in this spirit, I do not dispute Szasz's right to differentiate clearly between Ronald Laing and himself, provided the evidence supports his arguments. Unfortunately, however, Szasz employs a good deal of exaggeration and distortion to achieve his purpose.

For example, in his 2002 IFPE address, and in his recent remarks in the JSEA, Szasz cites a line from The Divided Self to "prove" that Laing favored involuntary hospitalization. That line reads: "When I certify someone insane, I am not equivocating when I write that he is of unsound mind, and may be dangerous to himself and others, and requires care and attention in a mental hospital". Judging from the testimony of Dr. Richard Gelfer, whom I interviewed in 1992, and who roomed with Laing and his family from 1957 to 1961, Laing probably composed these lines sometime in 1958 - perhaps as late as 1959. He was 30 or 31 years old at the time, and not obliged - indeed, not even allowed - to treat certifiable patients in the course of his clinical duties. On the contrary, his duties at the Tavistock Clinic and the Institute of Psycho-Analysis in London involved him with neurotics, the "walking wounded", on a voluntary, out patient basis. So these remarks, striking as they are, do not reflect his professional activities at the time.

Moreover, to the best of my knowledge, Laing never committed anyone to a mental hospital after The Divided Self was published in 1960. What was the basis for the remark Szasz cites, then? From 1951 to 1953, Laing did his psychiatric training in the British Army, where he differentiated (to the best of his ability) between malingerers and those who were genuinely deranged, and therefore incapable of fighting in the Korean war. And from 1953 till 1956, he held civilian psychiatric posts at the Royal Gartnavel Hospital and Southern General Hospital, where he was called upon to certify people insane from time to time. In short, prior to composing the line that Szasz seizes on, there was an interval of five years at the beginning of Laing's career when he did hospitalize patients, possibly against their will. But from 1956 till 1987, when his medical license was finally revoked, Laing hospitalized no one, to my knowledge, and worked diligently to create therapeutic communities that would function as viable alternatives to mental hospitals. In other words, Laing wrote these lines when he was 30 or 31, and a psychoanalyst in training, and spent the next 31 years (and more) living them down.

Moreover, it is instructive to note that during the first two years of the five year interval when Laing did certify patients insane, he was still training as a psychiatrist. Does this constitute grounds for reproach? Dr. Szasz is psychiatrist/psychoanalyst, is he not? Does Dr. Szasz maintain that he never treated involuntary mental patients during his psychiatric training, as Laing did - then ceased to do? If so, then the circumstances in which Szasz became a licensed psychiatrist were unusual indeed! When you take these mundane matters into account, Szasz's lofty appeal to principles, and his claim that Laing "approved" of involuntary hospitalization seems opportunistic or obtuse, to say the least.

Another factor worth considering in evaluating Szasz's charge is a contextual-hermeneutic one. Laing did indeed declare "I am not equivocating" when certifying that someone is insane. And clearly, he meant it at the time. But the full meaning of this statement only becomes clear when it is juxtaposed with a subsequent (and equally emphatic) statement to the effect that many "sane" people, who are deemed competent by their peers (and prevailing community standards) pose a much greater threat to the safety and well-being of others than the average mental patient. Indeed, in the preface to the Pelican edition of The Divided Self, Laing went so far as to say "In the context of our present pervasive madness that we call normality, sanity, freedom, all our frames of reference are ambiguous and equivocal". In short, Laing's intention was to impress upon the reader that he did not minimize the severity of distress or the potential harm entailed in a psychotic episode, but that he did not rate the sanity of "normal" (i.e. a-symptomatic) individuals, who are called upon to diagnose and treat such cases, very highly, urging his readers to ponder their social and cultural surroundings more carefully before they did until this point. The fact that none of this registers in Szasz's interpretation of Laing's statement strikes me as very significant, and characteristic of his whole approach to Laing.

Not content to leave matters there, Szasz goes on to say that Laing "used" involuntary hospitalization in the "management" of his first family, who returned to Glasgow after his divorce in 1964. This is quite misleading, because his daughter Fiona's first hospitalization, in 1977, followed a break-up with her current boy friend. Tragic as it was, her confinement to hospital was neither instigated nor approved by Laing, who was in London when it occurred, and was informed of her situation only after the fact. Though Laing did little to extract Fiona from Gartnavel after her hospitalization, or to prevent her from receiving ECT, as Adrian Laing points out, it was probably because he deemed any effort to intervene on her behalf doomed from the start. Why?

Consider the context. When Laing left his post at Gartnavel, in 1956, he was a highly respected psychiatrist who was on very friendly terms with Dr. Angus McNiven and Dr. Ferguson Rodger, who jointly ran the facility. Two decades later, however, Gartnavel was under new management, and Laing had earned a reputation as the pre-eminent critic of mainstream psychiatry. Through his remaining friends and colleagues in Glasgow, Laing was still fairly current with the situation at Gartnavel, and probably knew or strongly suspected that the new brass would greet any of his overtures or representations on Fiona's behalf with cold hostility. Why? Because Laing had spent most of the past two decades criticizing the mentality and methods of mainstream psychiatry, and Fiona's crisis could be used to discredit him, personally and professionally.

As I picture the scene (from Laing's perspective), he figured that since the effort to remove or protect Fiona from ECT would probably be futile, that he might as well spare himself and his first family the shame and embarrassment that would inevitably accrue from making a public stink about the matter. And he probably reckoned - correctly, I think - that if Fiona were released from Gartnavel, it would be into her mother's custody, not his. Hence the remark: "Well, Ruskin Place or Gartnavel, what's the difference"?

If we take the pertinent historical evidence into account, this statement probably represented a vote of non-confidence in Anne Laing's ability to restore her daughter's emotional equilibrium, rather than an endorsement of involuntary hospitalization per se. Was that judgment kind or fair? Perhaps not . But that is not the issue. Anyone who is well informed about Laing's situation at the time will appreciate that his passivity was probably the result of a (more or less) rational appraisal of the situation, in which he balanced the possible benefits to Fiona against the probable harm to himself and his first family - and doubtless, to his second family, who would share his shame and frustration if his efforts to help Fiona created an embarrassing media circus. To say that he sanctioned or approved of Fiona's hospitalization, or "used it" to "manage" his first family is to put the worst possible construction on his behavior.

In framing my objections to Szasz's attack this way, I hoped that a lucid and fair-minded acknowledgement of the pertinent historical and contextual data would help to make my case. But on reflection, we really needn't even go that far. Subtracting all the specific historical and contextual determinants may make our case more effectively. So for the sake of clarity and emphasis, let me re-state my argument in the following, hypothetical terms.

Let us say that you have a colleague who divorced and re-married, whose first family lives in a city several hundred miles from him. Unbeknownst to your colleague, an estranged son or daughter from his first marriage experienced a severe romantic disappointment, and was hospitalized involuntarily. And let us imagine that, for one reason or another, your colleague feels helpless to intervene on his estranged child's behalf without potentially doing harm to himself and others in the process. Finally, imagine that when you consider your colleague's behavior toward his first family, you hold him at least partially responsible for creating the familial instability that led to his child's breakdown, which resulted, eventually, in (his or her) hospitalization.

Now then, given the preceding, would you conclude that your colleague's current behavior was motivated by a tacit "approval" of involuntary hospitalization, or that he "used it" cynically to "manage his family"? Of course not , even if you disapproved of your colleague's previous behavior toward his distressed child (as you should). Why? Because that conclusion would not be warranted by the evidence. It is only one of several interpretive possibilities, and a pretty hostile one at that. Perhaps the most charitable thing one can say on behalf of Szasz's case against Laing is to render the old Scottish verdict: "Not proven".

The question then emerges: why does Szasz dredge up these sad tales of familial discord, and harp about Laing's drinking, and other outbursts or excesses? Well, as anyone familiar with his life knows, Laing was no saint. His neglect of his first family - (including but not limited to his daughter Fiona) - was absolutely shocking. So was Laing's (more or less contemporaneous) abuse of his erstwhile friend and collaborator, Aaron Esterson, with whom he co-authored "Sanity, Madness and the Family", and who, in due course, became Dr. Szasz's dear friend.

However, none of that excuses Szasz's use of distortion, exaggeration, taking statements out of context, and so on, to make his case. And even if he hadn't resorted to such base rhetoric, his overarching agenda - using Laing's personal failings and family woes to discredit his work and ideas - is intellectually bankrupt. Why?

As a youth in Toronto, I went to school with the children of some of Canada's most prominent psychoanalysts, psychiatrists and psychologists, and learned very quickly that the families of such people are not immune from the kinds of woes that afflict other families. And since my early twenties, I have researched the marital and family lives of Freud, Jung, Klein, Erikson and others - research which confirms my initial impressions a hundred fold. Being a mental health professional, even a very famous one, confers no special insight or immunity when it comes to the averting the anguish, conflict and confusion that engulf so many families. The fantasy that it is or should be otherwise is just that - a fantasy - for which there is no logical or empirical justification.

Consequently, in "The Wing of Madness: The Life and Work of R.D. Laing" (Burston, 1996), I argued that when evaluating someone's work in the mental health field, we must bracket their human failings, and let their theories stand or fall on their own merits. This does not mean that we should jettison our critical faculties, or blunt our ethical sensibilities in the process. It merely means that we give someone's ideas - as ideas - a fair and impartial hearing, whether we approve of their behavior or not. And Szasz seems incapable of doing that - in print, anyway.

Leaving Laing aside now, there are other aspects of Szasz's work that are problematic for existential psychotherapists. For some time now, Szasz has maintained that psychotherapy is an essentially ethical enterprise - a secular "cure of souls" analogous, in some ways, to Catholic confession - even though the analyst's stance toward his patient/client, by Szasz's account, is more akin to the purely voluntary association between a Jewish rabbi and a fellow Jew than between a Catholic priest and his parishioner. In his IFPE address of November 2, 2002, Szasz stated: "Psychoanalysis possesses a valuable moral core that has never been properly identified and is now virtually unrecognized: it is, or ought to be, a wholly voluntary and reliably confidential human service, initiated and controlled largely by the client who pays for it (p.2)." To keep this ethical relationship intact, says Szasz, the practitioner must confine his or her role to conversing with the client in the privacy of a professional office, and to completely refrain from "meddling in" their life outside it. As Szasz points out:

"In Freud's day, it did not occur to people - least of all to lawyers or psychiatrists - that it was an analyst's duty to protect a client from killing himself. Nor would it have occurred to people that it was the analyst's duty to protect so-called third parties or the community from the potential violence of the client. Today, protecting the "mental patient" from himself - the anorexic from starving to death, the depressed from killing himself, the manic from spending his money - is regarded as one of the foremost duties of anyone categorized as a mental health professional, psychoanalysis included." (p.6)

Unfortunately, Szasz continues

" . . . a person professing to help a fellow human being in distress cannot be a double agent; he must choose between serving the interests of the client, as the client defines them; or serving the interests of the client's family or employer or insurance company, or the interests of his profession, religion, community, or the state, as they define them. As a rule, this view is either ignored or dismissed with the claim that a so-called mental patient's "true (mentally healthy) interests cannot conflict with the interests of his "loved ones" or those of his community. If they do, it is because of his mental illness. The denial that the therapist deals with persons in conflict with others and that the process of therapy cannot - except accidentally or derivatively - help persons whose interests oppose or thwart those of the client characterizes virtually all modern therapies. For example, Constance T. Fischer, professor of psychology at Duquesne University, introduces the 2002 special double issue of The Humanistic Psychologist with this sentence: "In this collection of articles, psychologists approaches to assessment are compassionate, caring, deeply respectful of the humanity of the clients, and courageous in efforts to be genuinely helpful to all parties " (Fischer, 2002, p.1, emphasis in the original). This is self-congratulation concealing personal and professional self-aggrandizement. People whose lives are full of harmonious co-operation with others do no seek and are not subjected to mental health services" (p. 7).

This passage warrants careful scrutiny. But before outlining my various misgivings, please note that I share Szasz's contempt for the vulgar misconception that " . . . a so-called mental patient's "true (mentally healthy) interests cannot conflict with the interests of his "loved ones" or those of his community. If they do, it is because of his mental illness." Admittedly, "mental illness", can provoke, prolong or intensify existing conflicts, and even add new ones to a patient's life. But as Erich Fromm was apt to point out, inner and interpersonal conflicts can also be symptomatic of health - the manifest expressions of an intact and vibrant social conscience, of a desire for rational self-assertion, or a need to puncture the pretences and illusions that more complacent or conformist souls habitually mistake for truth (Burston, 1991).

On reflection, there is probably no more potent method for silencing dissatisfaction, dissent and the sense of having been violated or misunderstood than by treating (inner or interpersonal) conflict per se as symptomatic of "mental illness". Why? Because if human history is any indication , conflict is ubiquitous, and inscribed deeply in the whole human condition. The hope or expectation that an authentic human life can be lived without experiencing acute conflict is positively utopian, and the transposition of this naïve idyll into a normative or prescriptive ideal that is used to invalidate the legitimate problems and concerns of patients lacks generosity and realism.

Having said that, however, I strongly object to Szasz's contention that Constance Fischer's introduction to the double issue of The Humanistic Psychologist (2002), which he cites briefly, implies a thoughtless endorsement of this way of thinking. I have worked alongside Dr. Fischer at Duquesne University for more than a decade, and can attest that the kind of collaborative psychological assessment she teaches to our graduate students - who authored many of the articles in this issue of The Humanistic Psychologist - does not take instances of inner or interpersonal conflict to be symptomatic of "mental illness" per se. Nor would a careful perusal of Fischer's work substantiate this careless attribution.

Moreover, and more importantly, in terms of general principles for clinical practice, it is quite possible to be compassionate and respectful toward the client, and to put their interests first, while still trying to be helpful to the clients "significant others". To argue the contrary is to assume, in effect, if not in quite so many words, that the client is always so deeply embroiled in conflict that he or she shares no common or important interests with his or her family, friends, employers, etc., or none deep or potent enough to mitigate the severity of the client's difficulty. This is sometimes, but not always, the case.

Meanwhile, framing the whole issue in such starkly adversarial terms, as Szasz does, is quite revealing, and there are many reasonable people who would shun the services of a mental health professional whose ostensible zeal on behalf of the client's interests pits them in adversarial struggle with others from the outset, as a matter of course. And note that Szasz's case against Fischer rests on a single sentence, on which he hangs a very weighty condemnation supported by little (or in her case, no) evidence, as it did with Laing in The Divided Self. Admittedly, he carries this off with apparent conviction and great rhetorical skill. But are his convictions grounded in a searching and fair-minded analysis of the pertinent texts, or are they merely a cover for his apparent unwillingness to engage Laing and Fischer fairly on their own intellectual terrain?

Leaving the relationship between context and content, and questions of interpretation aside, let us reframe the substantive issues at stake here in slightly different terms. Szasz presents mental health professionals with two stark alternatives: "he must choose between serving the interests of the client, as the client defines them; or serving the interests of the client's family or employer or insurance company, or the interests of his profession, religion, community, or the state, as they define them." The prospect of being a "double agent", as Szasz calls it, and therefore, presumably, of betraying the client's trust and confidence isn't very appealing, of course. But on reflection, neither is the alternative, which is "serving the interests of the client, as the client defines them". This broad definition of the therapist's task could apply with equal validity to the services of a prostitute or a hired assassin, and therefore stands in stark contrast to Szasz's repeated insistence that the analytic dialogue is an ethical one. Why?

Because in an ethical dialogue, the therapist must be able to take some critical distance from "the interests of the client, as the client defines them", and help the client to do the same, if and when the client's perceived interests do not coincide with their deeper, human interests. Does this mean that the therapist is the "expert" on ethics, and therefore in a position to prescribe or legislate for the patient how he or she should live? Of course not! Therapists must wrestle with the same ethical questions their client's face, but also call attention to those they avoid facing. Szasz admits as much when he writes: "The psychoanalyst's job is to help his client live as honestly and responsibly, and hence as freely, as he can or wants to". But fostering ethical reflection in this sense is not really possible if the therapist is merely the agent or instrument of his client, if the client "calls the shots" and simply decides that he cannot or will not reflect seriously on the interests of others, as they define them. Another way of saying this is that Szasz's emphasis on honesty, responsibility and freedom puts too much emphasis on the client's relationship to himself, at the expense of his being with (and for) others.

Admittedly, Szasz's way of framing things has a stark Manichean verve and simplicity that appeals to radical individualists and libertarians. But for us existentialists, rightly or wrongly, our "being for ourselves" and "being for others" cannot be so radically divorced - at least, not without penalty. In fairness to Szasz, of course, there are indeed many instances when an individual's right of self-determination cuts against the grain of collective common sense. Take the subject of suicide. Elderly people, and those unfortunate souls who suffer from severe, chronic pain, or disabling and disfiguring diseases, who are experiencing a steady and irreversible deterioration in their quality of life, have every right to take their lives in the manner they choose, and at the time they choose, rather than leave their deaths to fate, or the impersonal ministrations of the medical profession, to decide. We have no right to impugn the mental health of people who take their lives voluntarily in such circumstances, rather than impoverish and inconvenience their families, or placate the kinds of medical professionals who have convinced themselves that they know better than their terminal patients what is "good" for them, etc., but lack the decency and insight to let them be. Strange as it may sound, on the face of it, suicide in such circumstances can be an act of freedom, of transcendence over the blind cruelty of circumstances, a resounding affirmation, an existential statement: "I am!". And I am not the first to say so, of course.

But what of the starving teenager or young adult whose only "illness" is that she thinks she is appallingly fat, unattractive, detestable, when she actually so emaciated that she resembles a survivor from Auschwitz? Unlike the elderly, chronically ill or deeply disabled person, her horizons of possibility have been constricted, not by physical hardships and limitations, but by misguided beliefs, and/or by prevailing cultural beliefs or expectations, etc. She has not yet lived, and to allow such a one to take her own life "freely" without attempting to alert or assist her family in any way is perverse, in my view.

Admittedly, by valuing life above the principle of confidentiality, we are making an ethical judgment - the wrong one, in Szasz's view; the right one, in mine. And similar constraints prevent us from maintaining complete confidentiality when a client's behavior poses a grave risk to another human being. If (for whatever reason) a client clearly plans to maim or kill someone else, and his therapist neglects to inform the client's intended victim or someone else in a position to warn or assist them, the therapist becomes an accomplice to mischief or murder. Confidentiality has limits, and the priest/confession analogy, which Szasz cites repeatedly, does too. Because of their calling, priests have a right and a responsibility to maintain confidentiality at all costs. Therapists do not. Psychotherapists are not "secular priests" or confessors, just as they are not surgeons. The priest analogy is far more apt and serviceable than the therapist-as-surgeon, in most contexts. But this is not one of them.

Between the chronically ill or elderly adult who hopes to die with dignity and the anorexic teenager whose judgment is addled there are all kinds of intermediate cases that are more difficult to judge, at least on the issue of confidentiality. These two cases, different as they are, are relatively clear cut, while many others we could mention occupy an intermediate position, and are anything but clear. There is a plenty of muddle in the middle, on which reasonable people are likely to disagree.

So, some say, if confidentiality is not sacred and inviolable, as Szasz contends, what about involuntary hospitalization? Should psychotherapists limit their clients' liberty and right to self-determination by committing them against their will? I think not. Szasz is quite right that psychotherapy ceases to be psychotherapy when an element of coercion - however benignly intended - enters into it. Once a therapist commits a client to hospital against their will and wishes, they cease to function as a therapist, and must rely on some combination of medication, coercion and old-fashioned persuasion to get results. Therapists should stick to their proper role and function, and not usurp the legal or medical profession's practices or prerogatives.

That's all very well, some say. But there are many instances where breaking confidentiality will likely result in an involuntary commitment, or indeed, in criminal charges, with the result that people other than the therapist deprive the client of his liberty, with the result that the client's trust in the therapist is irrevocably shattered. If so, that cannot be helped. Some things are more precious than the therapeutic alliance.

In any case, reading Szasz's reflections on liberty and confidentiality, one sometimes gets the impressions that his clear-cut, crystalline ethical principles are designed to spare us the agonizing and often inconclusive reflections that many clinicians face frequently in the course of their work. Szasz's problem is not that he suffers from an excess of "conviction" as Hugh Heatherington remarked. Rather, it is his rigid adherence to abstract ethical principles that admit of no exceptions, and that preclude the possibility of doubt or regret. Szasz lives in an imaginary world where one and the same ethical principle - the right to suicide, or to absolute confidentiality in all imaginable circumstances - applies equally to all people, regardless of age, background and condition. As a result, his ethical judgments, though enviably clear and consistent, on a purely logical plane, often lack realism, generosity and simple "common sense."